NCLEX Questions 230 #1
A client sustained a significant loss of blood after a motor vehicle accident. The nurse notes that the clients urine output has decreased and suspects that which hormones have influenced this clients fluid balance? Standard Text: Select all that apply. 1. Aldosterone 2. Angiotensin 3. Antidiuretic hormone 4. Estrogen 5. Progesterone
1,2,3
A client tells the nurse about rarely feeling thirsty. The nurse realizes that further assessment is needed to evaluate Standard Text: Select all that apply. 1. status of osmotic pressure. 2. vascular volume. 3. presence of angiotensin. 4. urine output. 5. body weight.
1,2,3
A nurse educator believes computers can enhance student learning. Which actions should the instructor take to demonstrate this belief? Standard Text: Select all that apply. 1. Allow students to research a nursing topic either by going to the library or via an online literature search. 2. Require a student to remediate after a failed test by completing appropriate computer-assisted instruction modules. 3. Use PowerPoint slides to reinforce complex concepts during classroom lectures. 4. Assign a collaborative group project to students enrolled in an online course. 5. Use computer-generated graphics to make written material less monotonous.
1,2,3,4
The nurse has removed the sutures from a clients surgical wound. What should the nurse document about this procedure? Standard Text: Select all that apply. 1. Number of sutures removed 2. Appearance of the incision 3. Client teaching 4. Client tolerance of the procedure 5. Name of the surgeon.
1,2,3,4
The nurse is completing a preoperative assessment with a client. What should this assessment include? Standard Text: Select all that apply. 1. Current health status 2. Allergies 3. Current medications 4. Mental status 5. Respiratory rate
1,2,3,4
The nurse is obtaining preoperative assessment data. What should be included in this assessment? Standard Text: Select all that apply. 1. Current health status 2. Allergies 3. Current medications 4. Mental status 5. Mothers maiden name
1,2,3,4
The nurse is preparing to complete a physical assessment before surgery. Which assessments should the nurse obtain? Standard Text: Select all that apply. 1. Mini mental status 2. Assessment of hearing 3. Assessment of the respiratory system 4. Gastrointestinal assessment 5. Maintain NPO status
1,2,3,4
A client is scheduled for lung resection surgery. What should the nurse keep in mind when determining this clients degree of risk for this major surgical procedure? Standard Text: Select all that apply. 1. Age 2. Medications 3. General health 4. Blood pressure 5. Nutritional status
1,2,3,5
The nurse has identified the goals of maintaining client safety and homeostasis during the intraoperative phase of client care. What nursing activities would support these goals? Standard Text: Select all that apply. 1. Maintain the sterile field. 2. Perform instrument counts. 3. Instruct in postoperative exercises. 4. Position the client appropriately for surgery. 5. Perform preoperative skin preparation.
1,2,4,5
The nurse is caring for a client who has just had a lumbar puncture. What should the nurse document about this clients procedure? Standard Text: Select all that apply. 1. Date and time performed 2. The physicians name 3. The clients ability to void after the procedure 4. The color, character, and amount of cerebrospinal fluid withdrawn 5. The clients status after the procedure
1,2,4,5
The nurse is preparing to instruct a client on leg exercises to be used when recovering from abdominal surgery. What should the nurse determine before beginning this teaching? Standard Text: Select all that apply. 1. Type of surgery 2. Time of surgery 3. Postoperative diet 4. Preoperative orders 5. Name of the surgeon
1,2,4,5
The nurse is beginning a physical assessment of a client who is freelance computer information technologist. On which areas should the nurse place particular emphasis during this assessment? Standard Text: Select all that apply. 1. Vision 2. Hearing 3. Back flexibility 4. Hand range of motion 5. Range of motion of arms
1,3,4,5
The nurse is participating in the development of a research study. What elements of the computer should the nurse ensure are in place before the study begins? Standard Text: Select all that apply. 1. Computer speed adequate 2. Print drivers installed 3. Word processing program 4. Computer storage capacity adequate 5. Appropriate software programs
1,3,4,5
A client has just completed a bone marrow biopsy. What should the nurse document about the client at this time? Standard Text: Select all that apply. 1. Clients tolerance of the procedure 2. Bowel sounds 3. The site for bleeding 4. Status of deep tendon reflexes 5. Presence of pain and any pain medication received
1,3,5
A client in the postanesthesia care unit is to have suction applied through a nasogastric tube. When documenting, the nurse should include which information? Standard Text: Select all that apply. 1. The time suction was started 2. Characteristics of wound drainage 3. Pressure on the suction 4. Integrity of the surgical dressing 5. Color and consistency of drainage
1,3,5
A client is scheduled for a bronchoscopy. What should the nurse instruct the client about this procedure? Standard Text: Select all that apply. 1. Tissue samples may be taken for biopsy. 2. Eating will not be permitted for 12 hours. 3. A local anesthetic is sprayed on the throat. 4. Bed rest for 8 hours is necessary after the test. 5. Informed consent is required for this procedure.
1,3,5
The nurse educator is considering ways to impact the learning of students through the use of computer technology. Which actions should the educator take to achieve this goal? Standard Text: Select all that apply. 1. Assign distance learners to conduct a research study of current evidence-based articles on caring for the diabetic client. 2. Expect that notification of clinical absences be provided by e-mail. 3. Require a clinical group to make daily reflective entries in an online journal. 4. Provide extra credit for academic work that is created on a computer as an electronic file. 5. Encourage the learners to access online NCLEX review questions as a way to assess their classroom learning.
1,3,5
The nurse is planning a perioperative clients needs upon discharge. What should be included when determining these needs? Standard Text: Select all that apply. 1. Clients abilities to provide self-care 2. Date of anticipated discharge 3. Physician performing the surgery 4. Financial resources 5. Need for home health care services
1,4,5
The nurse needs to obtain a urine specimen from a client with an indwelling urinary catheter. What should the nurse do when collecting this specimen? Standard Text: Select all that apply. 1. Withdraw 30 mL of urine for a routine urinalysis. 2. Perform catheter care before obtaining the specimen. 3. Apply sterile gloves before retrieving the urine specimen. 4. Send the specimen immediately or refrigerate it for later pickup. 5. Clamp the drainage tubing for 30 minutes if there is no urine in the catheter
1,4,5
The nurse is preparing to discontinue a clients intravenous infusion. Which actions should the nurse take when removing the catheter from the vein? Standard Text: Select all that apply. 1. Pull the catheter out in line with the vein 2. Apply pressure to the site while removing the catheter. 3. Pull the catheter out at an angle perpendicular to the vein. 4. Bend the clients elbow if bleeding at the site persists after removal. 5. Apply pressure to the site after the catheter is removed for 2 to 3 minutes.
1,5
The nurse is reviewing orders for parenteral potassium. Which order is safe for the nurse to implement? 1. Add 20 mEq of KCL to 1,000 mL of IV fluid 2. 10 mEq KCL IV over 12 minutes 3. Dilute 20 mEq KCL in 3 mL of NS and give IV push 4. 10 mEq KCL SQ
1. Add 20 mEq of KCL to 1,000 mL of IV fluid
The client has been placed on a 1200-mL oral fluid restriction. How should the nurse plan for this restriction? 1. Allow 600 mL from 73, 400 mL from 311, and 200 mL from 117. 2. Instruct the client that the 1200 mL of fluid placed in the bedside pitcher must last until tomorrow. 3. Offer the client softer, cold foods such as sherbet and custard. 4. Remove fluids from diet trays and offer them only between meals.
1. Allow 600 mL from 73, 400 mL from 311, and 200 mL from 117.
A client is prescribed a diagnostic test requiring a 24-hour stool specimen. What should this test indicate to the nurse? 1. Analyze the stool for dietary products and digestive secretions. 2. Detect the presence of bacteria or viruses. 3. Detect the presence of ova and parasites. 4. Determine the presence of occult blood.
1. Analyze the stool for dietary products and digestive secretions.
The nurse is teaching a client with heart failure about diagnostic tests. Which test should the nurse emphasize in this teaching? 1. BNP 2. CBC 3. LDH 4. PKU
1. BNP
The nurse wants to search for articles having to do with a client care problem. Which database should the nurse use to find this information? 1. CINAHL 2. Google 3. ERIC 4. PsychINFO
1. CINAHL
During the assessment of a client recovering from surgery, the nurse notes decreased breath sounds in both lower lobes bilaterally. What should the nurse do? 1. Coach the client to deep-breathe and cough. 2. Restrict fluids. 3. Remind the client to perform leg exercises. 4. Maintain on bed rest.
1. Coach the client to deep-breathe and cough.
The nurse needs to complete mandatory continuing education on client safety as part of a regulatory requirement for the hospital. Which computerized approach should the nurse consider to complete this required education? 1. Complete a computerized tutorial on client safety 2. Read information on safety from a web site 3. Review the online hospital policies about client safety 4. Complete a literature review on client safety
1. Complete a computerized tutorial on client safety
The client is admitted to the acute care unit with a phosphorus level of 2.3 mg/dL. Which nursing intervention would support this clients homeostasis? 1. Encourage consumption of milk and yogurt. 2. Enforce strict isolation protocols. 3. Encourage consumption of a high-calorie carbohydrate diet. 4. Strain all urine.
1. Encourage consumption of milk and yogurt.
The mother of a 1-month-old infant is concerned because the infant has had vomiting and diarrhea for 2 days. What instruction should the nurse give this infants mother? 1. Have the infant be seen by a physician 2. Give the infant at least 2 ounces of juice every 2 hours. 3. Measure the infants urine output for 24 hours. 4. Provide the infant with 50 mL of glucose water.
1. Have the infant be seen by a physician
The nurse is preparing to collect a throat culture from a client. What client response indicates to the nurse that teaching about this test has not been effective? 1. I need to hyperextend my neck. 2. I need to say ah.' 3. I will need to sit up. 4. The nurse will use a light.
1. I need to hyperextend my neck.
A client is to have an echocardiogram. Which statement by the client indicates the teaching about the test has been effective? 1. Im told this test causes no discomfort. 2. I will have to walk on a treadmill. 3. I will need to remain NPO. 4. I will need to take my pulse prior to the test.
1. Im told this test causes no discomfort.
The nurse is preparing to conduct preoperative teaching. What should be included in this teaching? 1. Information related to what will happen to the client 2. Referral of the client to the physician for any misconceptions the client may have 3. The role of the nurse during surgery 4. How to perform activities of daily living (ADLs) following surgery
1. Information related to what will happen to the client
A client is having a lumbar puncture. In which position should the nurse place the client? 1. Lateral with head bent toward the chest and knees flexed onto the abdomen 2. Lying prone, with the knees drawn up toward the abdomen 3. Sitting bent over from the waist with legs extended 4. Supine with knees pulled toward the chest
1. Lateral with head bent toward the chest and knees flexed onto the abdomen
The nurse is caring for a client in the immediate postoperative period (PACU). Which intervention should the nurse implement to reduce the risk of thrombophlebitis? 1. Leg exercises 2. Coughing every 2 hours 3. Ambulating every 2 hours 4. Oxygen by mask
1. Leg exercises
The nurse is admitting a client to the medical-surgical unit following a cholecystectomy. Which assessment should the nurse perform first? 1. Level of consciousness 2. Dressing 3. Drains 4. Skin color
1. Level of consciousness
The nurse is caring for a client who is receiving intravenous fluids that are not regulated on an electronic controller. In order to calculate the rate of the IV flow in drops per minute, the nurse must know the number of drops per milliliter of fluid the tubing delivers. Where should the nurse look for this information? 1. On the packaging of the tubing 2. In the charting from the nurse who started the infusion 3. In the drug reference book 4. On the roller clamp of the tubing
1. On the packaging of the tubing
The nurse is preparing a 23-year-old female client for surgery. The nurse should anticipate which diagnostic test to be prescribed for this client? 1. Pregnancy test 2. EEG 3. EKG 4. Pulmonary function tests
1. Pregnancy test
The nurse is caring for a client who is having surgery and is currently being transported to the operating room suite. The nurse should document that the client is in which operative phase? 1. Preoperative phase 2. Intraoperative phase 3. Postoperative phase 4. Perioperative phase
1. Preoperative phase
An older client is having difficulty handling the specimen cup for a clean catch urine specimen. What can the nurse do to help this client? 1. Provide a clean funnel to pour the urine into the specimen cup. 2. Document that the specimen could not be obtained. 3. Catheterize the client for the specimen. 4. Ask the physician to obtain the specimen.
1. Provide a clean funnel to pour the urine into the specimen cup.
A client has experienced a narcotic overdose. What acidbase imbalance should the nurse expect to observe in this client? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
1. Respiratory acidosis
The nurse initiates a blood transfusion for a client. What action should the nurse take next? 1. Stay with the client and closely observe him for the first 5 to 10 minutes of the transfusion. 2. Assign the UAP to sit with the client for 15 minutes. 3. Advise the client to notify the nurse if he experiences any chilling, nausea, flushing, or rapid heart rate. 4. Return to the room and take a set of vital signs in 15 minutes.
1. Stay with the client and closely observe him for the first 5 to 10 minutes of the transfusion.
The nurse is caring for an 80-year-old client preparing for surgery. The nurse realizes this client is at increased risk for which reason? 1. The physiological deficits of aging increase the surgical risk for older adults. 2. The older adult has increased kidney function. 3. The older adult has an increase in sensory function. 4. The older adult will turn, cough, and deep-breathe more effectively.
1. The physiological deficits of aging increase the surgical risk for older adults.
A client recovering from surgery asks the nurse why turning, deep breathing, and coughing exercises need to be done. What should the nurse respond? 1. These exercises help prevent pneumonia. 2. The doctor ordered the exercises. 3. All surgical clients must do these exercises. 4. These exercises prevent thrombophlebitis.
1. These exercises help prevent pneumonia.
The physician has ordered 50 mL of an IV solution to infuse over the next 20 minutes. In order to accurately infuse this solution, the nurse should set the electronic controller to deliver how many mL/hr?
150 mL/hr
A client is receiving a continuous intravenous infusion. What should the nurse document in the medical record about this infusion? Standard Text: Select all that apply. 1. Latest body temperature 2. Type of solution and flow rate 3. Total intravenous intake for the shift 4. Status of the intravenous catheter site 5. Results of blood pressure measurement
2,3,4
The nurse is instructing a female client on how to cleanse the perineum before collecting a clean catch urine specimen for culture and sensitivity. What should the nurse instruct this client to do? Standard Text: Select all that apply. 1. Clean the perineal area using a circular motion. 2. Use all towelettes provided. 3. Use each towelette once, and discard. 4. Clean the perineal area from back to front. 5. Clean the perineal area from front to back.
2,3,5
The nurse is preparing to start an IV in the hand of a client who has very small veins. Which actions would be useful in dilating the veins? 1. Position the hand at heart level. 2. Stroke the vein. 3. Have the client clench and unclench the fist. 4. Slap the back of the clients hand. 5. Massage the vein.
2,3,5
A client is anxious about receiving general anesthesia for a surgical procedure. What should the nurse explain are the advantages of having this type of anesthesia? Standard Text: Select all that apply. 1. The client remains conscious. 2. Respiratory rate can be regulated easily. 3. It is used for minor surgical procedures. 4. The anesthesia can be adjusted to the length of the operation. 5. It focuses on a single nerve or nerve group.
2,4
The nurse is planning to remove the sutures from a clients surgical wound. What should the nurse do before removing the sutures? Standard Text: Select all that apply. 1. Apply clean gloves. 2. Verify the order for suture removal. 3. Ambulate the client to the bathroom. 4. Read the order to determine whether a dressing is to be applied after removal. 5. Remove the dressing and clean the incision.
2,4,5
The nurse is providing care to a client during the posttest phase of diagnostic testing. What will the nurse do during this phase? Standard Text: Select all that apply. 1. Provide emotional and physical support to the client. 2. Compare the previous and current test results. 3. Prepare the client for the test. 4. Modify nursing interventions as necessary. 5. Report the results to appropriate health team members.
2,4,5
The nurse is collecting equipment to administer a unit of packed red blood cells. Which IV fluid should be used to initiate the IV for this transfusion? 1. 1,000 mL of lactated Ringers solution 2. 250 mL of normal saline 3. 500 mL of 5% dextrose and water 4. 100 mL of 5% dextrose and 1/2 normal saline
2. 250 mL of normal saline
A client is scheduled for a nuclear imaging test. What should the nurse instruct the client about this test? 1. It is the use of a magnetic field to produce an image of a body part or organ. 2. A radioisotope will be injected to determine organ functioning as being either hot or cold. 3. It produces a three-dimensional image of an organ. 4. It is more sensitive than an x-ray image.
2. A radioisotope will be injected to determine organ functioning as being either hot or cold.
The nurse is preparing to apply antiembolic stockings to a postoperative client. What should be done first, before applying the stockings? 1. Measure the calf. 2. Assess for circulatory problems. 3. Assess the clients blood pressure. 4. Clean the stockings.
2. Assess for circulatory problems.
The nurse is planning care for a client during the postoperative period. What should the nurse identify as the goal of care for this client? 1. Provide necessary preoperative teaching. 2. Assist the client to achieve the most optimal health status possible. 3. Ensure client safety. 4. Maintain an aseptic environment.
2. Assist the client to achieve the most optimal health status possible.
What should the nurse instruct a client for obtaining a clean voided urine specimen? 1. Collect at least 5 mL of urine. 2. Collect the first voided specimen in the morning. 3. Keep the specimen on ice. 4. Void in a sterile cup.
2. Collect the first voided specimen in the morning.
The nurse is assisting a client with a diagnostic test. Which role should the nurse expect to perform in the intratest phase? 1. Assess the data. 2. Collect the specimen. 3. Observe the client. 4. Prepare the client.
2. Collect the specimen.
The client who has an IV with an intermittent infusion lock in place wishes to shower. What action should be taken by the nurse? 1. Have the UAP discontinue the lock. 2. Cover the lock with an occlusive dressing. 3. Place a piece of cloth tape under the lock, wrapping the top in a U shape. 4. Tell the client that a bed bath is necessary until the IV is discontinued.
2. Cover the lock with an occlusive dressing.
Ten minutes after the transfusion of a unit of packed red blood cells was initiated, the client complains of a headache. The nurse assesses that the client has slight shortness of breath and feels warm to the touch. What action by the nurse is priority? 1. Notify the clients physician. 2. Discontinue the transfusion. 3. Slow the rate of the transfusion. 4. Prepare to resuscitate the client.
2. Discontinue the transfusion.
The nurse enrolled in graduate courses is able to continue studies while visiting abroad. What has this nurses nursing school implemented to make this possible? 1. Classroom technology 2. Distance learning 3. CAI 4. Informatics
2. Distance learning
The nurse is assessing an abdominal wound in the postoperative period. Which sign should indicate to the nurse that an infection is present? 1. Absence of bleeding 2. Edges warm to the touch 3. Edges well approximated 4. Sutures in place
2. Edges warm to the touch
An older client receiving intravenous fluids at 175 ml/hr is demonstrating crackles, shortness of breath, and distended neck veins. The nurse recognizes these findings as being which complication of intravenous fluid therapy? 1. An allergic reaction to the antibiotics in the fluid 2. Fluid volume excess 3. Pulmonary embolism 4. Speed shock
2. Fluid volume excess
What is the responsibility of the nurse when collecting a specimen from a client? 1. Always accompany the client to collect a specimen. 2. Handle the specimen discreetly. 3. Clean technique should be used with all specimen collection. 4. Use day-old specimens.
2. Handle the specimen discreetly.
A client asks what is done to keep computerized personal health information confidential. How should the nurse respond? 1. Dont worry; your information is always safe. 2. Information in our system requires a password to retrieve. 3. Our system was designed with a lot of input from nursing staff. 4. I can see why youre worried, with all the computer hackers out there these days.
2. Information in our system requires a password to retrieve.
The nurse wants to assess a client for orthostatic hypotension. What action should the nurse take? 1. Assess the client for dependent edema and then raise the legs to the level of the heart and reassess for edema. 2. Measure the clients heart rate and blood pressure in both the sitting and standing position. 3. Measure the clients blood pressure before, during, and after administration of a normal saline fluid challenge. 4. Raise the clients legs above heart level and measure the blood pressure.
2. Measure the clients heart rate and blood pressure in both the sitting and standing position.
The nurse is collecting a sputum specimen from a client. Which action should the nurse take during the collection of this specimen? 1. Collect at least 30 mL of sputum. 2. Offer mouth care. 3. Take shallow breaths. 4. Wear a mask.
2. Offer mouth care.
The nurse is preparing a 6-year-old child for a tonsillectomy. Which strategy should the nurse use for teaching this client? 1. Pamphlets 2. Play 3. Books 4. Videotapes
2. Play
The nurse is preparing a care plan for a client about to undergo surgery. Which nursing diagnosis would take priority during the intraoperative phase of surgery? 1. Ineffective Protection 2. Risk for Aspiration 3. Impaired Skin Integrity 4. Risk for Falls
2. Risk for Aspiration
A client has had a subclavian central venous catheter inserted. What should the nurse assess as a priority for this clients care? 1. Presence of bibasilar crackles 2. Tachycardia 3. Decreased pedal pulses 4. Headache
2. Tachycardia
The clients arterial blood gas report reveals a pH of 6.58. How does the nurse evaluate this value? 1. There is a slight elevation. 2. This value is incompatible with life. 3. This is a low normal value. 4. This value is extremely elevated.
2. This value is incompatible with life.
A client is being treated for tuberculosis, and the doctor writes an order to collect a sputum specimen. What is the rationale behind this order? 1. To test for acid-fast bacillus 2. To assess the effectiveness of therapy 3. To identify origin, structure, function, and pathology of cells 4. To identify the specific organism
2. To assess the effectiveness of therapy
A client is admitted to the hospital after vomiting for 3 days. Which arterial blood gas results should the nurse expect to find in this client? 1. pH 7.30; PaCO2 50; HCO3 27 2. pH 7.47; PaCO2 43; HCO3 28 3. pH 7.43; PaCO2 50; HCO3 28 4. pH 7.47; PaCO2 30; HCO3 23
2. pH 7.47; PaCO2 43; HCO3 28
The nurse is accessing information about standard classification of terms prior to documenting in a clients computerized clinical record. Which systems should the nurse consider using for this documentation? Standard Text: Select all that apply. 1. ANA 2. HIPAA 3. NANDA 4. The Omaha system 5. HHCC 6. NOC
3,4,5,6
A client is scheduled to have abdominal ascites fluid removed. What should the nurse instruct the client about this procedure? 1. A catheter will be inserted into the bladder. 2. A liver biopsy will be done. 3. An abdominal paracentesis will be done. 4. A thoracentesis will be done.
3. An abdominal paracentesis will be done.
The nurse has just inserted a nasogastric tube for gastric suction. What is the most reliable test for confirming tube placement? 1. Place the stethoscope over the stomach and listen for a swishing sound while inserting water into the tube. 2. Place the stethoscope over the stomach and listen for a swishing sound while inserting air into the tube. 3. Aspirate stomach contents and check the acidity using a pH test strip. 4. Connect the tube to suction and observe the contents.
3. Aspirate stomach contents and check the acidity using a pH test strip.
The nurse is caring for a client who is recovering from surgery. Which intervention should the nurse implement to decrease the clients possibility of developing hypercalcemia? 1. Measure vital signs every 4 hours. 2. Assist the client to turn, cough, and deep breathe every 2 hours. 3. Assist the client to ambulate around the room at least three times daily. 4. Irrigate the clients nasogastric tube every 2 hours.
3. Assist the client to ambulate around the room at least three times daily.
A small nursing program has limited access to clinical sites, especially those with specialty areas. What should the nurse educators consider as an option to allow students hands-on simulated clinical experience in these areas? 1. A field trip to a larger nursing institution 2. Videos 3. CAI 4. Workbook with written study guides
3. CAI
A client on diuretic therapy has a serum potassium level of 3.4 mg/dL. Which food should the nurse encourage this client to choose from the dinner menu? 1. Baked chicken 2. Green beans 3. Cantaloupe 4. Iced tea
3. Cantaloupe
A client is scheduled for a barium enema. What is the nursing priority for this client? 1. Assess bowel sounds. 2. Assess for allergies. 3. Cleanse the bowel. 4. Keep the client NPO.
3. Cleanse the bowel
The nurse needs to collect a specimen from a client; however, the nurse has never collected this type of specimen in the past. What should the nurse do? 1. Notify the physician. 2. Ask another nurse to collect the specimen. 3. Consult the nursing procedure manual. 4. Delegate the collection of the specimen to unlicensed assistive personnel.
3. Consult the nursing procedure manual.
The nurse needs to obtain a sputum specimen from a client. What should the nurse have the client do? 1. Apply sterile gloves. 2. Clear the throat. 3. Cough to bring up secretions. 4. Rinse the mouth with mouthwash prior to the collection.
3. Cough to bring up secretions.
A nurse educator has taught the same courses for the past 5 years and each year implements a few minor changes. Over this time, the educator has stored the grade data, including homework and assignment scores, in order to track trends following the implemented changes. What is the educator using to maintain this information? 1. Informatics 2. Student record management 3. Data warehousing 4. Management information system (MIS)
3. Data warehousing
The nurse is caring for a client who is receiving IV therapy at a rate of 10 mL/hour. The 500-mL IV bottle was hung at 0900 Monday morning when the IV catheter was initiated. It is now 0900 on Tuesday morning. What nursing action should be taken? 1. Refigure the rate of the IV. 2. Infuse the remaining IV fluid before hanging a new bag. 3. Discard the remaining IV fluid and hang a new bag. 4. Discontinue the IV site and restart an IV in the opposite hand.
3. Discard the remaining IV fluid and hang a new bag.
The client complains of burning along the vein in which a medicated IV is infusing. Upon assessment, the nurse finds the IV site is slightly reddened, but not warmer than the surrounding skin, and without swelling. What action should be taken by the nurse? 1. Slow the IV infusion and reassess the area in 15 minutes. 2. Apply ice over the IV site and vein. 3. Discontinue the IV and place a warm pack on the area. 4. Call the physician for direction.
3. Discontinue the IV and place a warm pack on the area.
The nurse is caring for an 80-year-old client with the medical diagnosis of heart failure. The client has edema, orthopnea, and confusion. Which nursing diagnosis is most appropriate for this client? 1. Heart Failure related to edema, as evidenced by confusion 2. Fluid Volume Deficit related to loss of fluids, as evidenced by edema 3. Excess Fluid Volume related to retention of fluids, as evidenced by edema and orthopnea 4. Excess Fluid Volume related to congestive heart failure, as evidenced by edema and confusion
3. Excess Fluid Volume related to retention of fluids, as evidenced by edema and orthopnea
The nurse is reviewing laboratory results for a client. Which diagnostic study determines how well blood glucose levels have been controlled in the client? 1. Blood chemistry 2. Capillary blood glucose 3. Hemoglobin A1c 4. Serum electrolytes
3. Hemoglobin A1c
The nurse is caring for a client who is being mechanically ventilated. Arterial blood gas analysis reveals respiratory acidosis. Which change in ventilator settings should the nurse anticipate? 1. Decrease in oxygen delivery 2. Decreased tidal volume of each breath 3. Increased respiratory rate 4. Increase in humidification of inspired air
3. Increased respiratory rate
The nurse is caring for a client on the postoperative unit. Which nursing diagnosis is the priority for this client? 1. Self-Care Deficit 2. Disturbed Body Image 3. Ineffective Airway Clearance 4. Risk for Falls
3. Ineffective Airway Clearance
The nurse suspects that a clients body is attempting to correct an acidbase imbalance. How will this imbalance be corrected? 1. Slow but efficient respiratory regulation will occur. 2. Primary regulation is through GI system losses. 3. Kidney regulation is powerfully effective. 4. The cardiovascular system is the major buffer.
3. Kidney regulation is powerfully effective.
A client tells the nurse about passing out after following a fasting diet for 5 days. Which acidbase imbalance should the nurse expect to assess in this client? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
3. Metabolic acidosis
A client asks the nurse, Why do I have to monitor my blood glucose levels? What is an appropriate response from the nurse? 1. Because your doctor ordered it. 2. If I were you, I would monitor the blood glucose when I didnt feel good. 3. Monitoring your blood glucose better enables you to manage your diabetes. 4. You can eat anything you want.
3. Monitoring your blood glucose better enables you to manage your diabetes.
After obtaining a unit of packed red blood cells for a client, the nurse learns the client needed to leave the care area for an emergency x-ray. What action should the nurse take? 1. Set up the blood with the IV fluid and y-tubing and place it on the IV stand in the clients room to initiate immediately after the client returns. 2. Place the blood in the unit refrigerator until the client returns. 3. Return the blood to the laboratory blood bank until the client returns. 4. Set up the blood with the IV fluid and y-tubing and place it in the unit medication room to initiate immediately after the client returns.
3. Return the blood to the laboratory blood bank until the client returns.
The nurse is caring for a client in the recovery area. In which position should the nurse place the unconscious client during the immediate postanesthesia phase? 1. Supine 2. Prone 3. Side-lying 4. Supine with a pillow under the head
3. Side-lying
The nurse is providing discharge instructions to a client who has been started on furosemide (Lasix) once daily. What information is essential to include in this information? 1. Take the medication at bedtime. 2. Avoid high-potassium foods. 3. Stand up slowly from a sitting position. 4. Do not take this medication on the days you take digitalis (Lanoxin).
3. Stand up slowly from a sitting position.
A client has orders for the administration of IV fluid at a keep vein open rate in preparation for administration of IV antibiotics starting at noon. When the nurse goes to the room to start the IV, the UAP is preparing to bathe the client. What should the nurse do? 1. Instruct the UAP to wait until the IV is started to bathe the client. 2. Let the UAP start the bath on the opposite side of where the nurse will be starting the IV. 3. Tell the UAP to notify the nurse as soon as the bath is completed. 4. Give the UAP permission to skip the clients bath for today.
3. Tell the UAP to notify the nurse as soon as the bath is completed.
The nurse is evaluating the effectiveness of preoperative instruction regarding leg exercises with a client recovering from surgery. Which observation indicates that the instructions were effective? 1. The lower extremity is swollen and hot to touch. 2. The vein feels hard. 3. There is no cramping or pain with ambulation. 4. There is pain in the calf with dorsiflexion.
3. There is no cramping or pain with ambulation.
A client is scheduled for a cholecystectomy. The nurse realizes that the purpose for this surgery is 1. diagnostic. 2. palliative. 3. ablative. 4. constructive.
3. ablative.
The nurse is preparing the skin of a client for surgery. The nurse knows the purpose of the surgical skin preparation is to 1. sterilize the skin. 2. assess the surgical site before surgery. 3. reduce the risk of postoperative wound infection. 4. clean any moles the client may have.
3. reduce the risk of postoperative wound infection.
The nurse is caring for a postoperative client with an abdominal wound and a drain. What can the nurse delegate to unlicensed assistive personnel? Standard Text: Select all that apply. 1. Clean the wound. 2. Assess the skin around the wound. 3. Determine the effectiveness of pain medication. 4. Report if the dressing is soiled. 5. Report if the dressing is loose.
4,5
The 154-pound adult client has had vomiting and diarrhea for 4 days secondary to a viral infection. What hourly urine measurement would indicate that efforts to rehydrate this client have not yet been successful and should continue? 1. 35 mL per hour 2. 80 mL per hour 3. 50 mL per hour 4. 30 mL per hour
4. 30 mL per hour
The nurse determines that interventions to prevent postoperative constipation have been effective in a client recovering from surgery. What did the nurse assess to make this clinical decision? 1. Abdominal distention present. 2. Gas pains present. 3. Client vomiting. 4. Bowel movement occurred 24 hours after resuming a normal diet.
4. Bowel movement occurred 24 hours after resuming a normal diet.
The nurse is preparing a client for an upper GI endoscopy. For which type of anesthesia should the nurse prepare the client to receive? 1. Local anesthesia 2. Spinal anesthesia 3. Epidural anesthesia 4. Conscious sedation
4. Conscious sedation
The nurse accesses previous hospitalization information to learn more about the clients previous health history. In what way is the availability of the clients health information assisting with the planning to address new care needs? 1. Ability to monitor quality 2. Access warehoused data (stored data) 3. Client sharing of knowledge that influences health 4. Constant availability of client health information
4. Constant availability of client health information
A client tells the nurse about researching on the Internet for information about a newly prescribed medication. What should the nurse respond to the client? 1. Im glad youre interested in your therapy. 2. Information on the Internet cannot be trusted. You should check with your pharmacist. 3. Your physician is the one you should be asking these kinds of questions. 4. Lets look at some of the sites youve been visiting.
4. Lets look at some of the sites youve been visiting.
The nurse wants to ensure that a client recovering from surgery does not develop thrombophlebitis. Which action should the nurse take to reduce the clients risk of this postoperative complication? 1. Administer an anticoagulant. 2. Assist the client to cough every 2 hours. 3. Monitor intake and output every 2 hours. 4. Provide for early ambulation.
4. Provide for early ambulation.
Unlicensed assistive personnel (UAP) will be conducting a test on a clients urine. What should the nurse instruct the UAP about the test? Standard Text: Select all that apply. 1. Nothing, because the UAP can perform urine testing. 2. Remind the UAP to tell the client the results of the test. 3. Notify the physician with the results of the test. 4. Report the results of the test to the nurse. 5. Save the urine, in case the nurse wants to repeat the test.
4. Report the results of the test to the nurse. 5. Save the urine, in case the nurse wants to repeat the test.
A nurse manager is responsible for scheduling the staff of all units in a critical care hospital. Which program should the manager use for computerized scheduling? 1. Database 2. Word processing 3. Graphics program 4. Spreadsheet
4. Spreadsheet
A client is having a timed urine collection done. The unlicensed assistive personnel does not save one specimen. What should the nurse do? 1. Continue with the test, and document that one specimen is missing. 2. End the test immediately, and send what is collected to the laboratory. 3. Document that the test cannot be completed. 4. Start the test over.
4. Start the test over.
Which return demonstration by a client indicates that teaching about performing a blood glucose monitoring test has been effective? 1. The client punctures the fingertip. 2. The client puts on gloves. 3. The client smears the blood on the reagent strip. 4. The client washes the hands.
4. The client washes the hands.
The nurse is reviewing instructions provided to a client about an upcoming cystoscopy. Which client response indicates that no further teaching is required? 1. During the procedure the physician will take x-rays. 2. I will be awake for this procedure. 3. The doctor will be able to see my kidneys. 4. The scope is a lighted instrument inserted through the urethra.
4. The scope is a lighted instrument inserted through the urethra.
Which instruction should the nurse give to the client when a stool specimen is to be collected? 1. Defecate in the toilet. 2. Follow sterile technique. 3. Send at least 60 mL of specimen. 4. Void before the specimen is collected.
4. Void before the specimen is collected.
A client with tattooed eyeliner is scheduled for an MRI. What should the nurse instruct the client about this diagnostic test? 1. Earplugs will be provided. 2. Lie very still. 3. Report any burning sensation. 4. Wear goggles.
4. Wear goggles.
The nurse is preparing to change the dressing on a clients postoperative wound. Place in order the steps the nurse should perform when removing the soiled dressing. Standard Text: Click and drag the options below to move them up or down. Choice 1. Assess the location, type, and odor of wound drainage. Choice 2. Remove the outer dressing. Choice 3. Discard the under dressing in a moisture-proof bag, and remove and discard gloves. Choice 4. Remove the under dressing. Choice 5. Apply clean gloves. Choice 6. Place the soiled dressing in a moisture-proof bag.
5,2,6,4,1,3
The nurse is to administer 75 mL of an antibiotic solution by IV over the next 30 minutes. The tubing has a drop factor of 20. How many drops per minute should the nurse set the controller to deliver?
50 drops per minute
